How does food insecurity relate to health and what are the - - PowerPoint PPT Presentation

How does food insecurity relate to health and what are the implications for health care providers?

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Valerie Tarasuk, PhD Professor, University of Toronto and principal investigator of PROOF Lynn McIntyre, MD, MHSc, FRCPC, FCAHS Professor Emerita, University of Calgary and PROOF investigator Carlota Basualdo-Hammond, MSc, MPH, RD Executive Director, Nutrition Services, Alberta Health Services

Household Food Security Survey Module

(administered on the Canadian Community Health Survey since 2004)

• Worry about not having enough food
• Reliance on low-cost foods
• Not being able to afford balanced meals
• Adults/children skip meals
• Adults/children cut size of meals
• Adults lost weight
• Adults/children not having enough to eat
• Adults/children not eating for whole day

“because there wasn’t enough money to buy food?” 18 questions, differentiating adults’ and children’s experiences over last 12 months:

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Marginal food insecurity Worry about running out of food and/or limit food selection because

• f lack of money for food.

Moderate food insecurity Compromise in quality and/or quantity of food due to a lack of money for food. Severe food insecurity Miss meals, reduce food intake and at the most extreme go day(s) without food.

Data Source: Statistics Canada, CCHS, 2007, 2008, 2011, and 2012.

• 12.6% of households
• over 4 million Canadians

(an increase of > 600,000 since 2007)

Household Food Insecurity in Canada, 2007 - 2012

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Household food insecurity Dietary compromises, stress, pervasive deprivation Physical and mental health problems

The deprivation and stress associated with food insecurity erode health and impede the management of chronic conditions.

DIETARY INTAKE & NUTRITIONAL STATUS

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Results of population-level analysis, CCHS 2004 (n ≈ 35,000, 10 provinces):

• Little evidence of nutrient inadequacies among young children, and few

differences in relation to household food insecurity.

• Adults and adolescents in moderately or severely food insecure

households had – poorer quality diets (i.e., fewer servings of milk products, fruits and vegetables, and for some groups, meat and alternatives) – higher risk of inadequate intakes for protein, vitamin A, folate, magnesium, phosphorus, zinc, iron (women), vitamin B6 (adults), vitamin B12 (adults).

(Kirkpatrick & Tarasuk, J Nutr, 2008: 138: 604-612)

The relation between household food insecurity and inadequate nutrient intakes:

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1 2 3 4 5 6 7 8 9 1-3 y 4-8 y M 9-13 y F 9-13 y M 14-18 y F 14-18 y 1 2 3 4 5 6 7 8 9 1-3 y 4-8 y M 9-13 y F 9-13 y M 14-18 y F 14-18 y

servings/day Age/sex group Food insecurity here includes only moderate and severe food insecurity. *Significant difference between food-secure & food-insecure subgroups, p<0.05

* *

Food secure Food insecure Recommended

Results from CCHS 2004 - Nutrition

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(Kirkpatrick & Tarasuk, J Nutr, 2008: 138: 604-612)

Children’s fruit and vegetable consumption, servings per day by food security status

1 2 3 4 5 6 7 8 9 1-3 y 4-8 y M 9-13 y F 9-13 y M 14-18 y F 14-18 y 1 2 3 4 5 6 7 8 9 1-3 y 4-8 y M 9-13 y F 9-13 y M 14-18 y F 14-18 y

servings/day Age/sex group Food insecurity here includes only moderate and severe food insecurity. *Significant difference between food-secure & food-insecure subgroups, p<0.05

* *

Food secure Food insecure Recommended

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(Kirkpatrick & Tarasuk, J Nutr, 2008: 138: 604-612)

Children’s fruit and vegetable consumption, servings per day by food security status

1 2 3 4 5 6 7 8 9

M 19-30 y F 19-30 y M 31-50 y F 31-50 y M 51-70 y F 51-70 y

1 2 3 4 5 6 7 8 9

M 19-30 y F 19-30 y M 31-50 y F 31-50 y M 51-70 y F 51-70 y

servings/day Age/sex group

Food secure Food insecure Recommended

* * * * *

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Food insecurity here includes only moderate and severe food insecurity. *Significant difference between food-secure & food-insecure subgroups, p<0.05

(Kirkpatrick & Tarasuk, J Nutr, 2008: 138: 604-612)

Adults’ fruit and vegetable consumption, servings per day by food security status

1 2 3 4 5 6 7 8 9

M 19-30 y F 19-30 y M 31-50 y F 31-50 y M 51-70 y F 51-70 y

servings/day Age/sex group Food insecurity here includes only moderate and severe food insecurity. *Significant difference between food-secure & food-insecure subgroups, p<0.05

(Kirkpatrick & Tarasuk, J Nutr, 2008: 138: 604-612)

Food secure Food insecure

1 2 3 4 5 6 7 8 9

M 19-30 y F 19-30 y M 31-50 y F 31-50 y M 51-70 y F 51-70 y

* * * * *

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Adults’ fruit and vegetable consumption, servings per day by food security status

500 1000 1500 2000 2500 3000 3500 4000 4500 M9-13 F9-13 M14-18 F14-18 M19-30 F19-30 M31-50 F31-50 M51-70 F51-70

mg/day

Food secure Food insecure

a: P < 0.05, comparison of transformed intakes; b: P<0.05, ANOVA adjusted for income, education, immigrant status, household composition, and current smoking. a,b a a

(Kirkpatrick & Tarasuk, J Nutr, 2008: 138: 604-612)

Mean SODIUM intake (mg/day), by age, sex and household food insecurity, CCHS 2004

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10 20 30 40 50 60 70 % inadequate intakes food secure food insecure

Note: food insecure defined as ≥ 3 affirmatives (USDA definition).

(Kirkpatrick et al, J Nutr 2015)

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Prevalence of nutrient inadequacy by food insecurity, individuals ≥ 9 years of age in Canada (CCHS 2004)

10 20 30 40 50 60 70 % inadequate intakes Canada FS Canada FI US FS US FI

Significantly greater difference between food secure and food insecure in Canada than US for calcium and magnesium.

Canada-US comparison of prevalence of nutrient inadequacy (≥ 9 yr) by household food security status

(Kirkpatrick et al, J Nutr 2015)

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e.g., Study of 294 Inuit children, 8-15 years of age, from Nunavik (Pirkle et al, Can J Public Health, 2014)

• 49.7% were living in food insecure households.
• Children in food-insecure households were significantly

shorter and had significantly lower hemoglobin levels than those in food-secure households.

• Even after adjustment for age, sex, etc, children in food-

insecure households were, on average, about 2 cm shorter.

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Food insecurity has been associated with much higher levels

• f nutritional vulnerability among specific subgroups.

RELATIONSHIP BETWEEN HOUSEHOLD FOOD INSECURITY AND BODY WEIGHT

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(Lyons et al, Am J Public Health 2007)

Prevalence of obesity for respondents 12 yr and older by sex and food security status, CCHS 2004:

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%

‘E’ reflects statistical uncertainty of estimate for food insecure males.

Adjusting for socio-demographic factors

• no significant association

between food insecurity and

• dds of obesity for males or

females.

• elevated odds only for women

reporting ‘food insecurity with mild hunger’ (≈ moderate food insecurity).

• Most consistent evidence of association is for adult women – not men

and not children. (see Eisenmann et al, Obes Rev 2010; Troy et al, Institute of Medicine, 2009)

• Existing literature is limited:

– Cross-sectional – Self-reported height and weight data – Food insecurity measured for last 12 months  relevant period of exposure? – Confounding by low income, race, parity, chronic ill-health, family structure, etc. (Franklin

et al, J Community Health 2012)

• Prospective studies from US show no evidence that food insecurity causes

weight gain among women. (Jones & Frongillo, Public Health Nutr 2007; Whitaker & Sarin, J Nutr 2007)

Relationship between food insecurity and body weight?

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HEALTH AND CHRONIC CONDITIONS

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Food insecurity is associated with a myriad of negative health outcomes across the life cycle.

• Qualitative research in Canada suggests food insecurity contributes to

early cessation of breastfeeding and struggles to afford needed formula.

(Frank, Food and Foodways, 2015; Partyka et al, Can J Diet Prac Res, 2010)

• Canadian evidence on pregnancy, birth outcome and early life health
• utcomes is lacking.
• US evidence suggests that food insecurity may increase the probability of

– Pregnancy complications (Laraia et al, J Am Diet Assoc, 2010) – Low birth weight, and birth defects (Carmichael et al, J Nutr 2007) – Poorer health and increased likelihood of hospitalization (Cook et al, J Nutr 2006) – Compromised development (Rose-Jacobs et al, Pediatrics, 2008; Hernandez & Jacknowitz, J

Nutr 2009)

Effects of food insecurity on pregnancy, birth outcomes, and early life

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• Children and youth who experienced hunger (ever) were

more likely to have poorer health.

• Multiple episodes of hunger were associated with higher
• dds of chronic conditions, including asthma.
• Child hunger predicted depression and suicidal ideation in

late adolescence and early adulthood.

• The pattern of depression among young adults who

experienced childhood hunger is more persistent than found in non-exposed possibly indicating bio embedding.

(Kirkpatrick et al., Arch Pediatric Adol Med 2010; McIntyre et al., J Affective Disorders 2013, McIntyre et al. J Social Psych Psych Epid, 2017)

Analyses of National Longitudinal Survey of Children and Youth (10-16 years of follow-up):

Food insecurity in childhood takes a lasting toll on health independent of other indicators of disadvantage

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(Tarasuk et al, unpublished analysis of CCHS 2007-08)

10 20 30 40 50 60

poor/fair self-rated health poor/fair self-rated mental health life stress

%

food secure marginally insecure moderately insecure severely insecure

Self-rated health status of adults 18-64 years, by household food insecurity status

10 20 30 40 50 60 no condition 1 condition 2 conditions ≥ 3 conditions

Food secure Marginally food insecure Moderately food insecure Severely food insecure

Conditions: asthma arthritis back problems bowel disorders diabetes heart disease hypertension migraines mood/anxiety disorder stomach/intestinal ulcers

%

(Tarasuk, Mitchell, McLaren & McIntyre, J Nutr, 2013)

Prevalence of chronic conditions among adults, 18-64 years, by household food security status, CCHS 2007-08

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5 10 15 20 25 30 35 40 45 50

men women men women men women food secure marginal insecurity moderate insecurity severe insecurity

%

Diabetes

Hypertension Heart disease

(Tarasuk, Mitchell, McLaren & McIntyre, J Nutr, 2013)

Proportion of Canadian adults (18 - 64 years) reporting selected chronic conditions, by food security status

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%

Back problem Mood or anxiety disorder Asthma

5 10 15 20 25 30 35 40 45 50

men women men women men women men women

food secure marginal insecurity moderate insecurity severe insecurity

Arthritis

(Tarasuk, Mitchell, McLaren & McIntyre, J Nutr, 2013)

Proportion of Canadian adults (18 - 64 years) reporting selected chronic conditions, by food security status

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(Jessiman-Perreault & McIntyre, under review)

Food insecurity gradient for 6 adverse mental health outcomes, CCHS 2005-2012 (unadjusted)

• Evidence of bidirectionality: 3 year follow up study of female

welfare recipients in Michigan in 1997. (Heflin, Siefert & Williams,

2005; Heflin, Corcoran & Siefert, 2007 )

• Evidence from Britain and US that mothers’ mental health can

temporally precede food insecurity (Melchior, et al., 2009; Garg et al,

2015). [usual assumption is that food insecurity precedes mental illness]

Mental illness Food insecurity The relationship between food insecurity and mental health appears to be bidirectional.

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CHRONIC DISEASE MANAGEMENT

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• 70% prevalence of food insecurity documented among HIV-positive

individuals in Canada. (Anema et al, AIDS Care 2011)

• Results of systematic review and meta-analysis indicated that food-

insecure people had 1.32 times greater odds (95% CI: 1.15-1.53) of having lower CD4 counts, suggesting food insecurity is a barrier to immune

• recovery. (Aibibula et al, AIDS Care 2016)
• BC study of HIV-positive injection drug users found those reporting food

insecurity were almost twice as likely to die compared to those who were food secure, over 13 years of follow up. (Anema et al, PloS One2013)

29 (Aibibula et al. AIDS Care. 2016. Anema et al, AIDS Care 2011;23(2):221-30. Anema et al, PLoS One. 2013;8(5):e61277)

HIV Disease Status in the Context of Food Insecurity

• Increased likelihood of hospitalization among children with insulin-

requiring diabetes with food insecurity (Marjerrison et al, 2011) .

• Indications of poorer self-care among Canadian adults with diabetes and

moderate/severe food insecurity (Gucciardi et al, 2009).

• Among adults with diabetes mellitus in the United States, food insecurity

has been associated with more frequent hypoglycemic episodes (Seligman et al 2010a), poorer self-management (Seligman et al 2010a), increased need for health services (Seligman et al 2010b), and increased use of physician services (Nelson et al 2001).

30 (Marjerrison et al, J Pediatrics, 2011;158:607-11; Gucciardi et al, Diabetes Care 2009; 32:12. Nelson et al, J Gen Intern Med. 2001;16:404-11. Seligman et al, J Health Care Poor Underserved. 2010a;21(4):1227-

• 1233. Seligman et al. J Nutr. 2010b;140(2):304-10.

Managing Diabetes in the Context of Food Insecurity

• A US study has shown that food insecurity may contribute to

disparities in chronic kidney disease, especially among persons with co-morbid diabetes or hypertension (Crews et al, 2014).

• Implications for disease progression and dialysis?

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Managing Chronic Kidney Disease in the Context of Food Insecurity

HEALTH CARE COSTS

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500 1000 1500 2000 2500 3000 3500 4000

secure marginally insecure moderately insecure severely insecure

Prescription drugs Home care services Same day surgery Inpatient costs Physician services Emergency Other

$3930 $1608 $2161

$

$2806

(Tarasuk et al, Canadian Medical Association Journal, 2015)

Average health care costs per person incurred over 12 months for Ontario adults (18-64 years of age), by household food insecurity status:

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• Top 5% of health care users account for 2/3 of total health care

expenditures. Analysis of relation between food insecurity status and health care use in the next 5 years among a cohort of Ontario adults :

• Food-insecurity  46% greater odds of high-cost health care use in next

5 years, after taking into account baseline morbidity and other socio- demographic risk factors.

• Food insecurity = single strongest predictor of high-cost health care use.

(Fitzpatrick et al, American Journal of Preventive Medicine, 2015)

Household food insecurity also relates to the probability of high-cost health care use.

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SCREENING FOR FOOD INSECURITY

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Classic screening criteria in public health1.

• 1. The condition sought should be an important health problem.
• 2. There should be an accepted treatment for patients with recognized

disease.

• 3. Facilities for diagnosis and treatment should be available.
• 4. There should be a recognizable latent or early symptomatic stage.
• 5. There should be a suitable test or examination.
• 6. The test should be acceptable to the population.
• 7. The natural history of the condition, including development from

latent to declared disease, should be adequately understood.

• 8. There should be an agreed policy on whom to treat as patients.
• 9. The cost of case-finding (including diagnosis and treatment of

patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.

• 10. Case-finding should be a continuing process and not a “once and

for all” project.

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1http://www.who.int/bulletin/volumes/86/4/07-050112BP.pdf

Classic screening criteria in public health1.

Food insecurity arguably meets 2/10.

• 1. The condition sought should be an important health problem.
• 2. There should be an accepted treatment for patients with recognized

disease.

• 3. Facilities for diagnosis and treatment should be available.
• 4. There should be a recognizable latent or early symptomatic stage.
• 5. There should be a suitable test or examination.
• 6. The test should be acceptable to the population.
• 7. The natural history of the condition, including development from

latent to declared disease, should be adequately understood.

• 8. There should be an agreed policy on whom to treat as patients.
• 9. The cost of case-finding (including diagnosis and treatment of

patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.

• 10. Case-finding should be a continuing process and not a “once and

for all” project.

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1http://www.who.int/bulletin/volumes/86/4/07-050112BP.pdf

WHO emerging screening criteria: 10 additional challenges for food insecurity

• 1. The screening programme should respond to a recognized need.
• 2. The objectives of screening should be defined at the outset.
• 3. There should be a defined target population.
• 4. There should be scientific evidence of screening programme

effectiveness.

• 5. The programme should integrate education, testing, clinical services

and programme management.

• 6. There should be quality assurance, with mechanisms to minimize

potential risks of screening.

• 7. The programme should ensure informed choice, confidentiality and

respect for autonomy.

• 8. The programme should promote equity and access to screening for

the entire target population.

• 9. Programme evaluation should be planned from the outset.
• 10. The overall benefits of screening should outweigh the harm.

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http://www.who.int/bulletin/volumes/86/4/07-050112/en/

• What tool to use?

– options range from full 18 items on CCHS to 2 item subsets

• Who should do the screening?
• Mode of administration?
• Will screening capture severity of food insecurity?

BIGGEST Question: What are you going to do about it?

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More questions raised re screening method

WHY SCREENING MAY BE SEEM LIKE A GOOD IDEA

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1) Because chronic disease is more prevalent among food insecure individuals, they are over-represented in clinical populations.

e.g., 2010 survey of 314 adults diagnosed with diabetes mellitus receiving outpatient services at Calgary clinic (Galesloot et al, 2012) 8.3% reported moderate household food insecurity 6.7% reported severe household food insecurity Prevalence of moderate/severe food insecurity in Alberta in 2010: 7.2%

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(Galesloot et al, Can J Diet Prac Res 2012;73:e261-e266a; Tarasuk et al, 2014)

15.0%

2) Because one US authority has recommended screening for children’s exposure to household food insecurity.

• Argument in the US that screening can enable health care

providers to refer parents/caregivers for publicly funded food assistance programs (e.g., food stamps [SNAP], WIC) that will provide them with substantial resources. (See for example American

Academy of Pediatrics’ recommendation, October 2015.)

• In Canada, we have no comparable programs [nor is that the

answer]. Referrals to local food banks and other community food programs will yield nowhere near the same levels of

• assistance. Our safety net is income-based.

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3) Because screening social assistance recipients might get them special diet allowances.

food secure 39% marginally insecure 8% moderately insecure 24% severely insecure 29%

Food security status of households reliant on social assistance, CCHS 2014

43 (Adapted from Tarasuk, Mitchell & Dachner, Household Food Insecurity in Canada, 2014. 2016)

• In some jurisdictions,

additional benefits are available for recipients with special health needs (e.g., special diet allowances).

• BUT Social assistance

recipients are at such high risk of food insecurity that screening is unnecessary.

• Anyone who qualifies for

these benefits should be helped to access them (and they still require the disease).

Data Source: Canadian Community Health Survey, 2011/2012 and 2013/2014. Newfoundland and Labrador, Manitoba, British Columbia and Yukon Territory did not participate in the food security module of the 2013 and 2014 CCHS. Prince Edward Island and the Northwest Territories excluded due to small sample size. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% NU YT BC AB SK MB ON QC NB NS NL 2011/2012 2013/2014

Proportion of households reliant on social assistance who were food insecure in 2011-12 and 2013-14

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4) Because there is value in screening that nets referrals for assistance with income tax, etc to help ensure people access all benefits to which they are entitled.

• Identification of low income is sufficient.
• “Do you ever have difficulty making ends meet

at the end of the month?”

Brcic, Vanessa, Caroline Eberdt, and Janusz Kaczorowski (2011), “Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study,” International Journal of Family Medicine, vol. 2011. 45

• Food insecurity is related to dietary inadequacies.
• The health effects are pervasive and extend beyond nutrition-

related conditions.

• The health burden occurs along a gradient of increasing

severity, and it is costly.

• Bi-directionality has been observed in mental health.
• Disease management is impaired, worsening existing chronic

conditions.

• Screening remains unwarranted in regular healthcare settings.

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Summary

Investigators: Valerie Tarasuk (PI, U Toronto), Craig Gundersen (co-PI, U Illinois), Lynn McIntyre (U Calgary), Herb Emery (U Calgary), Catherine Mah (Memorial U), Jurgen Rehm (CAMH), Paul Kurdyak (CAMH) Funding: PROOF is supported by a Programmatic Grant in Health and Health Equity, Canadian Institutes

• f Health Research (CIHR) (FRN

115208).

For emerging research and resources, please visit our website: proof.utoronto.ca

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@proofcanada

IMPLICATIONS FOR HEALTHCARE PROVIDERS

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Malnutrition

Food Insecurity Chronic Disease/ Mental Illness

Not a significant contributor in Canadian population Contributes to dietary compromises, stress, pervasive deprivation

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Definition of Malnutrition

– A decline in lean body mass (with or without fat loss) that leads to functional impairment – 6 characteristics of malnutrition to aid in its diagnosis:

– Insufficient energy intake – Weight loss – Muscle mass loss – Subcutaneous fat mass loss – Edema – Hand grip strength

Consensus statement: American Academy of Nutrition and Dietetics; American Society for Parenteral and Enteral Nutrition (References: Jensen, 2012; Fearon, 2011; Evans, 2008)

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Risk Factors for Malnutrition vs Food Insecurity

Malnutrition

Unintended weight loss Poor intake Poor appetite Swallowing disorder Malabsorption Limited access to food Reduced functional status & mobility Frailty/ older age Diseases such as cancer, liver disease, kidney disease, HIV

Food Insecurity

Lower income Reliance on social assistance Renter (vs home owner) Presence of children under 18 yr (vs couple without children) Lone-parent female-led households Aboriginal or black respondent

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Nutrition Risk Screening- Older adults SCREEN II

14 questions covering issues that influence the nutritional health of seniors, including:

– Appetite – Frequency of eating – Motivation to cook – Ability to shop and prepare food – Weight changes – Isolation and loneliness – Chewing and swallowing – Digestion – Food restrictions due to health conditions

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Health System Implications

Food Insecurity: Inadequate or insecure access to food due to financial constraints Malnutrition Inadequate nutrient intake (especially protein & calories) related to barriers to food intake or increased needs Severe Food Insecurity : Indicates reduced food intake and disrupted eating patterns; highly clinically relevant for diet-sensitive conditions

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Impact of food insecurity on managing health conditions

↑ expenses required to manage condition

– equipment, supplies, medication

↑ costs to access healthcare services

– transportation, parking, childcare

↓ earnings

– poor health, loss of wages, ↓ energy and productivity

↓ energy to engage in financial coping strategies

– delay bill payments, seek loans, access charitable support

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Patient Care Considerations

• Simple, easy to use tools, needed for screening

malnutrition and food insecurity (or poverty)

• Tools need to be integrated into patient care

processes and made routine

• Ethical screening principles need to be followed

(i.e. appropriate interventions for those identified at risk)

• Clinicians need information about malnutrition

and food insecurity to improve care and patient

• utcomes

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Canadian Nutrition Screening Tool

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https://thewellhealth.ca/wp- content/uploads/2016/11/Poverty_flowAB-2016-Oct-28.pdf

Do you ever have difficulty making ends meet at the end of the month?

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What can health care providers do?

• Provide patient centered, collaborative care
• Assess: Determine if food insecurity is a problem/barrier

– Financial access to food – Find out more about patient’s situation/living condition – Assess questions about barriers and enablers to meet goals and manage chronic disease – Ask questions to identify if there are opportunities for funding which are not being accessed

• Educate: Ask if patient wants information/supports

– Provide information about government programs or health benefits – Provide information as appropriate about community services

• Work as a multidisciplinary team and connect patient with appropriate

services/resources

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Additional opportunities

• Understand patient and family perspectives on

how the health care system can provide better care for patients experiencing food insecurity

• Understand the prevalence of food insecurity for

those accessing health services

• Research on poverty screening and the impact of

screening on patient care and outcomes

• Improve education of health care providers

starting with undergraduate training

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Take Home Messages

• YOU can help raise awareness among health

care providers about how food insecurity impacts health

• Collective action is needed
• Need purposeful, evidence based approaches

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Acknowledgements

• Suzanne Galesloot
• Sheila Tyminski

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Moderator Presenters

Craig Larsen

Executive Director Chronic Disease Prevention Alliance of Canada

Valerie Tarasuk, PhD

Professor, University of Toronto and PROOF principal investigator

Lynn McIntyre, MD, MHSc, FRCPC, FCAHS

Professor Emerita, University

• f Calgary and PROOF

investigator

Carlota Basualdo- Hammond, MSc, MPH, RD

Executive Director, Nutrition Services, Alberta Health Services

@theCDPAC youtube.com/theCDPAC facebook.com/theCDPAC www.cdpac.ca 63